Rotator cuff: failure and treatment



Rotator cuff: failure and treatment

Abstract

Purpose of the review: Cuff failure is one of the commonest afflictions of the shoulder. This review synthesizes the current information regarding failure and treatment of the rotator cuff.

Recent Findings: Failure of the rotator cuff attachment arises when tensile loads overwhelm the strength of the enthesis: the weaker the tendon, the less the load necessary for failure. Atraumatic cuff tears usually arise insidiously and may respond to exercises directed at mobilization and deltoid strengthening. Atraumatically torn tendons may not be of sufficient quality or quantity for durable surgical repair. Acute traumatic tears provide the opportunity for a robust surgical reattachement. Healing of a failed cuff insertion can be accomplished by surgical reattachment to the tuberosity in a manner that excludes joint fluid, provides a smooth upper surface to articulate with the preserved coracoacromial arch, and maintains contact of the tendon edge with prepared bone for the many months required for restoration of the enthesis. This is most dependably achieved by an inlay technique without surgical knots on the bursal aspect of the tendon. If good quality tendon cannot be mobilized so that it can be secured to the attachment side with the adducted arm, lysis of adhesions, smoothing of the exposed tuberosity and a gentle manipulation under muscle relaxation can restore substantial comfort and function to the shoulder.

Summary: This review provides a rationale for current management of rotator cuff failure.

Key words: rotator cuff, surgical repair, inlay, coracoacromial arch.

Introduction

Over 3000 articles on the rotator cuff have been published in the last 20 years. This review summarizes our view of the most important articles relevant to the treatment of full thickness defects of the rotator cuff as it inserts to the tuberosities of the humerus.

I. Rotator cuff structure and function

The rotator cuff is a blend of glenohumeral capsule and insertional tendons of four scapulohumeral muscles: the subscapularis, the supraspinatus, the infraspinatus and the teres minor. [Clark Sidles 1990][Boon deBeer 2004] Clark, J., Sidles, J.A., and Matsen III, F.A.: The Relationship of the Glenohumeral Joint Capsule to the Rotator Cuff. Clin. Orthop., 254:29-34, 1990. Boon, J. M., M. A. de Beer, et al. (2004). "The anatomy of the subscapularis tendon insertion as applied to rotator cuff repair." J Shoulder Elbow Surg 13(2): 165-9.The cuff has several key functions: (1) to stabilize the humeral head by compressing it into the glenoid concavity, (2) to create a smooth articulation with the undersurface of the coracoacromial arch, Preserve smooth upper surface of cuff for articulation with acromion and (3) to provide rotational torque in internal rotation (subscapularis), elevation (supraspinatus), and external rotation (infraspinatus and teres minor).

These functions are each critical.

First, tThe ‘ball in socket’ stabilization by concavity compression in the normal shoulder precisely locates the humeral head in all glenohumeral positions, especially the mid range positions when the glenohumeral ligaments are lax and, thus, non functionalunable to contribute to stability. If the concavity is deficient or if the cuff muscle tendons are detached, this the concavity compression mechanism is compromised.

Second, tThe ‘ball and socket’ articulation with the coracoacromial arch is essential for stabilizing the proximal humerus from translating superiorly from the force applied by the deltoid or from the force of downward arm pressure on a walker or arm chair. [Romeo Loutzenheiser 1998] (Romeo, A. A., T. Loutzenheiser, Rhee, Y.G., Sidles, J.A., Harryman, D.T., Matsen, F.A. III: The humeroscapular motion interface. Clin Orthop Relat Res (350): 120-7, 1998.). In these situations the coracoacromial arch is subjected to substantial load by the subjacent cuff tendons (Matsen and Rockwood chapter on the rotator cuff, Fealey JSES Vol 14, 542 2005). [Rockwood and Matsen, 3rd edition, Chapter 15 page 800 figures 15-5 and 15-6.] If the supraspinatus tendon is absent, the ‘spacer’ function of the tendon is lostIf the loading of the coracoacromial arch is substantial over time, so that the head moves toward the acromioncalcification within this ligament may result that appears radiographically to be a ‘spur’ extending from the acromion. However it is to be noted that this traction spur within the ligament does not encroach on the cuff or humeral head below.[ Ogata Uhthoff 1990]. [Fealy April 2005] [Panni Milano 1996].[ [Chambler Bull 2003]. [Chambler Pitsillides 2003] [ Chambler Rawlinson 2004]. [Ogawa Yoshida 2005] [Fealey April 2005] When the supraspinatus tendon is absent, the ‘spacer’ function of the tendon is lost. If concavity compression into the glenoid is insufficient to maintain the centering of the head in the glenoid, the humerus moves upward. [Nove-Josserand Edwards 2005].Nove-Josserand L, Edwards TB, O'Connor DP, Walch G. The acromiohumeral and coracohumeral intervals are abnormal in rotator cuff tears with muscular fatty degenerationClin Orthop Relat Res. 2005 Apr;(433):90-6. This movement relatively slackens the deltoid, compromising its function. When the supraspinatus tendon is absent, the tuberosity becomes prominent so that the smooth passage of the humerus beneath the arch is lost.

Third, tThe rotational torques enable movements of the arm in positions where other muscles are relatively ineffective: the final 30 degrees of internal rotation by the subscapularis, elevation in the mid ranges of abduction by the supraspinatus, and external rotation beyond neutral by the infraspinatus and teres minor. The adequacy of these torques can be easily assessed on clinical examination. Their loss may result in weakness or instability of the shoulder.

The insertional anatomy of the cuff tendons is designed to resist the bending, compressive and tensile loads that they experience [Gigante Marinelli 2004][ Roh Wang 2000] Gigante, A., M. Marinelli, et al. (2004). "Fibrous cartilage in the rotator cuff: A pathogenetic mechanism of tendon tear?" J Shoulder Elbow Surg 13(3): 328-32.. The insertion includes fibers transitioning from tendon, to fibrocartilage, to calcified fibrocartilage to bone.[Thomopoulos Williams 2003 1 ] The upper surface blends smoothly with the tuberosities to create a spherical proximal humeral convexity that passes smoothly under the anterior edge of the coracoacromial arch at low angles of elevation, protecting the cuff insertion from abrasion from the acromion. [Ziegler 2004] (Ziegler, D. W. (2004). "The use of in-office, orthopaedist-performed ultrasound of the shoulder to evaluate and manage rotator cuff disorders." J Shoulder Elbow Surg 13(3): 291-7.). The critical juncture between the anterior supraspinatus and the upper subscapularis is reinforced by an intricate network of cross-linking fibers. [Clark Harryman 1992][ Kolts Busch 2002][Boon de Beer 2004] (Clark, J. M. and D. T. Harryman, 2nd (1992). "Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy." J Bone Joint Surg Am 74(5): 713-25.).

II. Rotator cuff failure

Rotator cuff tendons and their ability to repair and remodel can be weakened with age [Kumagai Sarkar 1994][ Sano Ishii 1997] [Sano Uhthoff1998][ Sano Ishii 1999][. Yamaguchi Tetro 2001][Harryman Hettrich 2003] (Harryman, D. T., 2nd, C. M. Hettrich, et al. (2003). "A prospective multipractice investigation of patients with full-thickness rotator cuff tears: the importance of comorbidities, practice, and other covariables on self-assessed shoulder function and health status." J Bone Joint Surg Am 85-A(4): 690-6. , Yamaguchi, K., A. M. Tetro, et al. (2001). "Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically." J Shoulder Elbow Surg 10(3): 199-203.),, by systemic disease (such as rheumatoid arthritis and diabetes), by smoking [Mallon Misamore 2004] ((Baumgarten), Mallon, W. J., G. Misamore, et al. (2004). "The impact of preoperative smoking habits on the results of rotator cuff repair." J Shoulder Elbow Surg 13(2): 129-32., by corticosteroids Chbinou, N. and J. Frenette (2004)., by non-steroidal anti-inflammatory medications [Tsai Hsu 2006][Cohen Kawamura 2006][Dahners Mullis 2004], by corticosteroids, and by systemic disease (such as rheumatoid arthritis and diabetes), [Chbinou Frenette (2004][Gotah Hamada 1997] (Tsai, W. C., C. C. Hsu, et al. (2006). "Ibuprofen inhibition of tendon cell migration and down-regulation of paxillin (a positive regulator of cell spreading and migration) expression." J Orthop Res. Cohen, D. B., S. Kawamura, et al. (2005). "Indomethacin and Celecoxib Impair Rotator Cuff Tendon-to-Bone Healing." Am J Sports Med. Dahners, L. E. and B. H. Mullis (2004). "Effects of nonsteroidal anti-inflammatory drugs on bone formation and soft-tissue healing." J Am Acad Orthop Surg 12(3): 139-43.). Weakened tendon is more susceptible to failure when bending, compressive or tensile loads are applied to it.[Soslowsky Thomopoulos 2002][Reilly Amis 2003 - 1] [Reilly Amis 2003 - 2][Reilly Bull 2003] The amount of force necessary to disrupt the cuff is a clinically useful indicator of the quality of the tendon. Thus, atraumatic failure of the cuff suggests tendon of poor quality whereas a strong tendon that requireds a major injury to tear it is more likely to be reparable..

When the cuff tendons become detached from their insertion to the tuberosity, the cuff muscle, tendon, and instertionalinsertional bone deteriorate at a relatively rapid rate[Barton Gimbel 2005][Gimbel VanKleunen 2004][Jiang Zhao 2002]. Ditsios Boyer 2003]. [Meyer Fucentese 2004][Geber Meyer 2004][ [Meyer Pirkl 2005][Yokota Gimbel 2005] Galatz Rothermich 2005][Meyer Hoppeler 2004] The circulation at the edge of a degenerative cuff lesion is also compromised in comparison to that of control tissue [Biberthaler Wiedemann 2003]. Because this deterioration is not rapidly reversed after reattachment of the tendonstendons [Fuchs Gilbart 2006], [Uhthoff Matsumoto 2003]prompt repair is recommended for acute, traumatic cuff tears. (Meyer, D. C., C. Pirkl, et al. (2005). "Asymmetric atrophy of the supraspinatus muscle following tendon tear." J Orthop Res 23(2): 254-8. Yokota, A., J. A. Gimbel, et al. (2005). "Supraspinatus tendon composition remains altered long after tendon detachment." J Shoulder Elbow Surg 14(1 Suppl S): 72S-78S. Meyer, D. C., S. F. Fucentese, et al. (2004). "Association of osteopenia of the humeral head with full-thickness rotator cuff tears." J Shoulder Elbow Surg 13(3): 333-7. Gerber, C., D. C. Meyer, et al. (2004). J Bone Joint Surg Am 86-A(9): 1973-82. Galatz, L. M., S. Y. Rothermich, et al. (2005). J Orthop Res 23(6): 1441-7. Ditsios, K., M. I. Boyer, et al. (2003). J Orthop Res 21(6): 990-6.

III. Manifestations of Rotator Cuff Tears

Patients with rotator cuff tears manifest a wide variability in their clinical presentation: some are essentially asymptomatic while others are disabled. [Duckworth Smith 1999][Smith Harryman 2000][Harryman Hettrich 2003] [MacDermid Ramos 2004] [Kelly Williams 2005] MacDermid, J. C., J. Ramos, et al. (2004). "The impact of rotator cuff pathology on isometric and isokinetic strength, function, and quality of life." J Shoulder Elbow Surg 13(6): 593-8. (Duckworth, D.G., Smith, K.L., Campbell, B., Matsen III, F.A.: Self-assessment questionnaires document substantial variability in the clinical expression of rotator cuff tears. J Shoulder Elbow Surg., 8(4):330-3, 1999.). Smith, K.L, Harryman II, D.T., Antoniou, J., Campbell, B., Sidles, J. A., and Matsen III, F.A.: A prospective multi-practice study of shoulder function and health status in patients with documented rotator cuff tears. J. Shoulder Elbow Surg., 9(5):395-402, 2000. Harryman II, D.T., Hettrich, C., Smith, K.L., Campbell, B., Sidles, J.A., and Matsen III, F.A.: A prospective multipractice investigation of patients with full thickness rotator cuff tears: The importance of co-morbidities, surgeon, and other co-variables on self-assessed shoulder function and health status. J. Bone Joint Surg., 85A(4): 690-696, 2003. In evaluating the patient at the time of presentation, it is valuable to assess the relative importance of (a) pain, (b) weakness, (c) stiffness, (d) roughness, and (e) instability as well as the chronicity of the deficits, the trauma involved at the inception, concurrent health and social concerns, and the details and effectiveness of treatment to date. It is critical to realize that the prevalence of cuff tears increases with age and that many of these tears are of no functional consequence. Thus it is not uncommon that an individual with socioeconomic distress, depression, cervical spondylosis, a worker’s compensation claim, or a hiatal hernia may be found on imaging evaluation to have a defect in their his or her rotator cuff.[Misamore Ziegler 1995] Misamore, G. W., D. W. Ziegler, et al. (1995). "Repair of the rotator cuff. A comparison of results in two populations of patients." J Bone Joint Surg Am 77(9): 1335-9.The existence of a chronic cuff defect is not of itself an indication for surgical management.

IV. Management of patients with rotator cuff problems

Patients with acute traumatic cuff tears should be advised to consider an acute repair, ideally within weeks of the injury. Patients with chronic and minimally traumatic cuff defects present no surgical urgency; the surgeon has ample time to get to know them and to try non-operative means for managing pain, weakness, stiffness, roughness and instability. (Haahr – Ann Rheum Dis 2005 May 64, 760), Levy) Goldberg, B.A., Nowinski, R.J., and Matsen III, F.A.: Outcome of non-operative management of full thickness rotator cuff tears. Clin Orthop, 382:99-107, 2001. [Haahr 2005][Goldberg Nowinski 2001]It is emphasized that failure of a patient to respond to non-operative management of a rotator cuff lesion does not mean and surgical management would be successful.

A. Principles in surgical management of full thickness rotator cuff defects

1. Preoperative estimation of reparability

A reparable cuff tear is one in which tendon of good quality can be brought to the anatomic insertion site with the arm adducted to the patient’s side. A cuff tear is likely to be reparable if it was torn by a forceful injury to a previously normally functioning shoulder and if the repair is within weeks of the injury. A cuff defect is less likely to be durably reparable if the patient is elderly, if the cuff defect occurred without a significant injury, if the cuff defect occurred in the distant past, if the shoulder shows substantial muscle atrophy, if the humeral head is superiorly displaced relative to the glenoid and acromion, if the patient is a smoker or otherwise unhealthy, if the patient has had multiple steroid injections into the shoulder, if the patient is on medications that interfere with healing, if the degree of weakness is severe, if there are other conditions affecting the shoulder and/or if the patient is not able to cooperate with the post operative protocol.. Preoperative imaging tests may support the view of irreparability if they demonstrate poor residual tendon quality, severe retraction, massive failure, or muscle deterioration. The goal of cuff repair surgery is to re-establish a durable attachement of tendon to bone through an enthesis.[Koike Trudel 2005] [Koike Trudel 2006].[Kumagai Sarkar 1994]Koike, Y., G. Trudel, et al. (2005). "Formation of a new enthesis after attachment of the supraspinatus tendon: A quantitative histologic study in rabbits." J Orthop Res 23(6): 1433-40. Koike, Y., G. Trudel, et al. (2006). "Delay of supraspinatus repair by up to 12 weeks does not impair enthesis formation: A quantitative histologic study in rabbits." J Orthop Res 24(2): 202-10.

2. Preoperative reconciliation of patient expectations with possible surgical findings and postoperative management.

More than with perhaps any other shoulder condition, it is essential that the patient understand that the ability of a rotator cuff to heal depends on (a) tissue of adequate quantity and quality, (b) robust reattachment of the tendon to bone, (c) a careful and slow rehabilitation process that assures that the tendon is protected from the premature application of loads that might risk the integrity of the repair. The patient must also understand that the final determination of reparability can only be made at surgery after the necessary releases have been carried out. [Gimbel Mehta 2004]Gimbel, J. A., S. Mehta, et al. (2004). "The tension required at repair to reappose the supraspinatus tendon to bone rapidly increases after injury." Clin Orthop Relat Res(426): 258-65. The patient must further understand that achieving a ‘good’ repair at surgery does not guarantee that the repair will hold up over time nor that normal shoulder comfort and function will be regained. Finally the patient should understand that often the comfort and the function of a shoulder with an irreparable cuff can be improved by subacromial smoothing by bursectomy, lysis of adhesions, resection of useless tendon fragments and rounding of the tuberosity and a gentle manipulation to assure full passive motion.

B. Surgical technique

1. Utility approach [ Matsen/Lippitt chapter on cuff repair]

The ‘deltoid-on’ approach provides excellent access to the subacromial space and cuff tendons without compromising the deltoid origin or the integrity of the coracoacromial arch. In this way, the risk of antero-superior escape of the proximal humerus from the stabilizing effect of the arch is minimized. In this cosmetic approach, the skin is incised along Langer’s lines and the deltoid split along its major raphe between the anterior and middle thirds. The subacromial space is entered. Any hypertrophic bursa, scar, adhesions or unusable fragments of tendon are resected and the humeroscapular motion interface is freed from the axillary nerve anteriorly to the axillary nerve posteriorly. (Matsen – section on rotator cuff in Matsen/Lippitt). A gentle manipulation under muscle relaxation is then performed to assure full passive mobility of the shoulder. The cuff tendon edges are identified and sutures passed through the lateral edges. There is no advantage in debriding debrindingdebriding the edge of the torn tendon. [Goodmurphy Osborn 2003] Goodmurphy, C. W., J. Osborn, et al. (2003). "An immunocytochemical analysis of torn rotator cuff tendon taken at the time of repair." J Shoulder Elbow Surg 12(4): 368-74.Releases of the tendon and subjacent capsule from the coracoid process and from the glenoid labrum are performed as necessary to determine if good quality tendon can be brought to the desired insertion site with the arm at the side.

2. Principles and procedure of reattachment of reparable cuff tendon [ Matsen Lippitt chapter on cuff repair]

If it is dermined determined that the tear is reparable with the arm at the side with reasonable quality tissue, the objective is to optimize both the mechanics and the biology of the repair. The desired mechanical characteristics include (a) a secure repair that mataintains maintains good contact between the tendon and bone without micromotion (even if should some slip of the suture or knot occur,s allowing the formation of a gap ) [Scheffler Sudkamp 2002] [Reilly Bull 2004]Reilly, P., A. M. Bull, et al. (2004). "Passive tension and gap formation of rotator cuff repairs." J Shoulder Elbow Surg 13(6): 664-7., (b) distribution of the load of the repair over as many sutures as possible, (c) reinforcement of the bone to tendon repair with side to side tendon-tendon sutures as the tear pattern requires, and (d) a congruent upper surface of the repaired cuff-tuberosity construct so that it articulates smoothly with the undersurface of the coraco acromial arch. [Ahmad Stewart 2005][Park Cadet 2005][Bicknell Harwood 2005][Ahmad Stewart 2005][Tuoheti Itoi 2005]Ahmad, C. S., A. M. Stewart, et al. (2005). "Tendon-bone interface motion in transosseous suture and suture anchor rotator cuff repair techniques." Am J Sports Med 33(11): 1667-71. Park MC, Cadet ER, Levine WN, Bigliani LU, Ahmad CS. Tendon-to-bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques. Am J Sports Med. 2005 Aug;33(8):1154-9. Bicknell RT, Harwood C, Ferreira L, King GJ, Johnson JA, Faber K, Drosdowech D. Cyclic loading of rotator cuff repairs: an in vitro biomechanical comparison of bioabsorbable tacks with transosseous sutures. Arthroscopy. 2005 Jul;21(7):875-80.

Ahmad CS, Stewart AM, Izquierdo R, Bigliani LU. Tendon-Bone Interface Motion in Transosseous Suture and Suture Anchor Rotator Cuff Repair Techniques.Am J Sports Med. 2005 Aug 10; Tuoheti, Y., E. Itoi, et al. (2005). "Contact area, contact pressure, and pressure patterns of the tendon-bone interface after rotator cuff repair." Am J Sports Med 33(12): 1869-74. Park, M. C., E. R. Cadet, et al. (2005). "Tendon-to-bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques." Am J Sports Med 33(8): 1154-9.The desired biological properties include exclusion of joint fluid from the healing site, maximal exposure of the tendon to fractured trabeculae and marrow cells, recognizing that the bone, rather than the tendon, is the source of healing. Aoki Oguma 2001][St Pierre Olson 1995][ Hamada Tomonaga 1997][ [Uhthoff Sano 2000][ [ Oguma Murakami 2001]. [Thomopoulos Hattersley 2002] Uhthoff Trudel 2003][ Koike Trudel 2005] Thomopoulos, S., G. Hattersley, et al. (2002). "The localized expression of extracellular matrix components in healing tendon insertion sites: an in situ hybridization study." J Orthop Res 20(3): 454-63.Uhthoff, H. K., H. Sano, et al. (2000). "Early reactions after reimplantation of the tendon of supraspinatus into bone. A study in rabbits." J Bone Joint Surg Br 82(7): 1072-6. St Pierre, P., E. J. Olson, et al. (1995). "Tendon-healing to cortical bone compared with healing to a cancellous trough. A biomechanical and histological evaluation in goats." J Bone Joint Surg Am 77(12): 1858-66. Uhthoff, H. K., G. Trudel, et al. (2003). "Relevance of pathology and basic research to the surgeon treating rotator cuff disease." J Orthop Sci 8(3): 449-56. Hamada, K., A. Tomonaga, et al. (1997). "Intrinsic healing capacity and tearing process of torn supraspinatus tendons: in situ hybridization study of alpha 1 (I) procollagen mRNA." J Orthop Res 15(1): 24-32. Koike JOR 23 2005 1433-1440. Oguma, H., G. Murakami, et al. (2001). "Early anchoring collagen fibers at the bone-tendon interface are conducted by woven bone formation: light microscope and scanning electron microscope observation using a canine model." J Orthop Res 19(5): 873-80.In many ways, the mechanics and the biology of cuff repair are analogous to the mechanics and biology of ACL reconstruction, where inlay of the tendon graft into bone is preferred used over rather than an onlay reattacmentreattachment to the “footprint” [Kawamura Ying 2005][Weiler Hoffmann 2002][Berg Pollard 2001][Wang Wang 2005][Kobayashi Watanabe 2005][Rodeo Arnoczky 1993][Ouyang Goh][Thomopoulos Soslowsky 2002][Goradia Rochat 2000][Robert Es-Sayeh 2003][Walsh Harrison 2004][Yamakado Kitaoka 2002][Martinek Latterman 2002][Greis Burks 2001][Leung Qin 2002][Wong Qin 2003]. Kawamura, S., L. Ying, et al. (2005). "Macrophages accumulate in the early phase of tendon-bone healing." J Orthop Res 23(6): 1425-32. Weiler, A., R. F. Hoffmann, et al. (2002). "Tendon healing in a bone tunnel. Part II: Histologic analysis after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep." Arthroscopy 18(2): 124-35. Berg (Arthroscopy 17(2) 189 2001) Wang, C. J., F. S. Wang, et al. (2005). "The effect of shock wave treatment at the tendon-bone interface-an histomorphological and biomechanical study in rabbits." J Orthop Res 23(2): 274-80. Kobayashi, M., N. Watanabe, et al. (2005). "The fate of host and graft cells in early healing of bone tunnel after tendon graft." Am J Sports Med 33(12): 1892-7. Rodeo, S. A., S. P. Arnoczky, et al. (1993). "Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog." J Bone Joint Surg Am 75(12): 1795-803. Ouyang, H. W., J. C. Goh, et al. (2004). "Use of bone marrow stromal cells for tendon graft-to-bone healing: histological and immunohistochemical studies in a rabbit model." Am J Sports Med 32(2): 321-7. Thomopoulos, S., L. J. Soslowsky, et al. (2002). Gordia Am J Knee Surg 13 143 2000) Goradia, V. K., M. C. Rochat, et al. (2000). "Tendon-to-bone healing of a semitendinosus tendon autograft used for ACL reconstruction in a sheep model." Am J Knee Surg 13(3): 143-51. Robert, H., J. Es-Sayeh, et al. (2003). "Hamstring insertion site healing after anterior cruciate ligament reconstruction in patients with symptomatic hardware or repeat rupture: a histologic study in 12 patients." Arthroscopy 19(9): 948-54. Walsh, W. R., J. A. Harrison, et al. (2004). "Patellar tendon-to-bone healing using high-density collagen bone anchor at 4 years in a sheep model." Am J Sports Med 32(1): 91-5. Yamakado, K., K. Kitaoka, et al. (2002). "The influence of mechanical stress on graft healing in a bone tunnel." Arthroscopy 18(1): 82-90. . Martinek, V., C. Latterman, et al. (2002). "Enhancement of tendon-bone integration of anterior cruciate ligament grafts with bone morphogenetic protein-2 gene transfer: a histological and biomechanical study." J Bone Joint Surg Am 84-A(7): 1123-31. Greis, P. E., R. T. Burks, et al. (2001). "The influence of tendon length and fit on the strength of a tendon-bone tunnel complex. A biomechanical and histologic study in the dog." Am J Sports Med 29(4): 493-7. Leung, K. S., L. Qin, et al. (2002). "A comparative study of bone to bone repair and bone to tendon healing in patella-patellar tendon complex in rabbits." Clin Biomech (Bristol, Avon) 17(8): 594-602. Wong, M. W., L. Qin, et al. (2003). "Healing of bone-tendon junction in a bone trough: a goat partial patellectomy model." Clin Orthop Relat Res(413): 291-302.

3. Principles and procedure of subacromial smoothing when tendon is not reparable.[ Matsen Lippitt chapter on smooth and move irreparable cuff tear]

In this situation, the goal is to assure full and smooth passive motion of the proximal humerus beneath the coracoacromial arch without sacrificing the stability provided by an intact arch. Once the tendon has been determined to be irreparable, any useless soft tissue between the humeral head and the arch is debrided leaving a smooth transition to any tendon remaining intact. If the tuberosity is relatively proud because of the absence of the cuff, it is smoothed until a congruent contour of the proximal humeral convexity is achieved. [Scheibel Lichtenberg]Matsen in Matsen Lippitt – Chapter on smooth and move for the irreparable cuff.

Scheibel, M., S. Lichtenberg, et al. (2004). "Reversed arthroscopic subacromial decompression for massive rotator cuff tears." J Shoulder Elbow Surg 13(3): 272-8.)

C. Post operative management

1. Management after cuff repair

Even with optimal repair techniques, the evidence is that months and even years are required before a bone-tendon repair remodels to a structure of reasonable strength.[Galatz Sandell 2006][Boyer Harwood 2003] Thomopoulos, S., G. R. Williams, et al. (2003). "Tendon to bone healing: differences in biomechanical, structural, and compositional properties due to a range of activity levels." J Biomech Eng 125(1): 106-13. (Galatz, L. M., L. J. Sandell, et al. (2006). "Characteristics of the rat supraspinatus tendon during tendon-to-bone healing after acute injury." J Orthop Res.) . Galatz, L. M., L. J. Sandell, et al. (2006). "Characteristics of the rat supraspinatus tendon during tendon-to-bone healing after acute injury." J Orthop Res. Gerber, C., A. G. Schneeberger, et al. (1999). "Experimental rotator cuff repair. A preliminary study." J Bone Joint Surg Am 81(9): 1281-90. For this reason, the post operativepostoperative protocol must minimize the risk of applying excess tension to the repair [Thomopoulos Williams 2003][Gerber Schneeberger 1999]. Gerber, C., A. G. Schneeberger, et al. (1999). "Experimental rotator cuff repair. A preliminary study." J Bone Joint Surg Am 81(9): 1281-90.. Pendulum exercises and other forms of gentle passive motion can prevent adhesions while minimizing the loading of the reattachment. The duration of the need for protection is not easily determined, so that a conservative return to active use is recommended. Smaller, more acute and traumatic tears in younger healthier individuals may be expected to heal more quickly. As a general guide, three months of passive exercises are often recommended followed by slowly progressive active assisted exercises and then by progressive active use of the arm. Activities involving impact or heavy loading of the cuff are discouraged for a year after repair surgery.

2. Management after subacromial smoothing without cuff repair

In this situation, rehabilitation is much simpler. Initially the emphasis is on achieving full passive range of motion. As soon as the shoulder has achieved this goal, progressive strengthening of the residual cuff muscles, the deltoid, and the scapula protractors and elevators is initiated.

D. Results

1. Comfort and function

Most patients experience improvement of shoulder comfort and function after rotator cuff surgery as long as complications such as infection, stiffness, and instability from sacrifice of the coracoacromial arch are avoided.[Soifer Levy 1996][Goldberg Lippitt 2001][Goldberg, B.A., Lippitt, S.B., and Matsen III, F.A.: Improvement in shoulder comfort and function after rotator cuff repair without acriomioplasty. Clin. Orthop., 382:99-107, 2001. McCallister, W.V., Parsons, I., Titelman, R.M., Matsen, F.A. III: Open Rotator Cuff Repair without Acromioplasty. J Bone Joint Surg Am., 87: 1278-1283, 2005.McCallister Parsons 2005][

2. Cuff integrity

When the integrity of the rotator cuff is studied by followupfollow-up MRI or ultrasound several years after cuff repair, most repairs of supraspinatus-only tears remain intact Fuchs, B., M. K. Gilbart, et al. (2006). "Clinical and structural results of open repair of an isolated one-tendon tear of the rotator cuff." J Bone Joint Surg Am 88(2): 309-16., but most repairs of two or three tendon tears show recurrent tendon defects.Itdefects. It is of note that the standpoint of comfort and function, many patients with recurrent defects are experience improved functional improvement in spite of recurrent defects after surgery. [Fealy Adler 2006][Boileau Brassart 2005][Galatz Ball 2004][Gleyze Thomazeau 2000][Gazielly Gleyze 1995][Gazielly Gleyze 1994]This suggests that the ‘repair’ may not be the essential element in the improvement in comfort and function after surgery. [Galatz Ball 2004]. [Gerber Fuchs 2000] [Zanetti Jost 2000][ Goutallier Postel 2003] Sperling Cofield 2004] Fealy, S., R. S. Adler, et al. (2006). "Patterns of vascular and anatomical response after rotator cuff repair." Am J Sports Med 34(1): 120-7. Boileau, P., N. Brassart, et al. (2005). "Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?" J Bone Joint Surg Am 87(6): 1229-40. Galatz, L. M., C. M. Ball, et al. (2004). "The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears." J Bone Joint Surg Am 86-A(2): 219-24. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005 Jun;87(6):1229-40. Gleyze, P., H. Thomazeau, et al. (2000). "[Arthroscopic rotator cuff repair: a multicentric retrospective study of 87 cases with anatomical assessment]." Rev Chir Orthop Reparatrice Appar Mot 86(6): 566-74. Gazielly, D. F., P. Gleyze, et al. (1995). "[Functional and anatomical results after surgical treatment of ruptures of the rotator cuff. 1: Preoperative functional and anatomical evaluation of ruptures of the rotator cuff]." Rev Chir Orthop Reparatrice Appar Mot 81(1): 8-16. Gazielly, D. F., P. Gleyze, et al. (1994). "Functional and anatomical results after rotator cuff repair." Clin Orthop Relat Res(304): 43-53.The principal correlate with anatomic cuff integrity is shoulder strength. [Harryman Mack 1991]Harryman II, D.T., Mack, L.A., Wang, K.Y., Jackins, S.E., Richardson, M.L., and Matsen III, F.A.: Rotator Cuff Repair: Correlation of Functional Results With Cuff Integrity. J. Bone and Joint Surgery, 73A:982-989, 1991.

V. Conclusion

Rotator cuff failure is one of the commonest conditions of the shoulder. Progressive atraumatic cuff failure may be minimally symptomatic while acute traumatic cuff failure may devastate a previously normally function shoulder. Repair of acute tears is a matter of relative urgency, while chronic atraumatic tears provide opportunity for rehabilitation and consideration of the overall needs of the patient. Surgical repair creates substantial mechanical and biological challenges: secure contact between good quality tendon and bone at the insertion site with the arm at the side with a smooth upper surface of the proximal humeral convexity are essential for optimizing the chances of durable healing. If these goals cannot be achieved, shoulder comfort and function can often be improved by a ‘smooth and move’ procedure in which the stability provided by the coracoacromial arch is carefully preserved.

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